Complaint·May 29, 2026

Investigation revealed the following: Allegation: “The facility did not ensure that resident was provided with comfortable, safe, and sanitary living accommodations.” It is being alleged that staff allowed R1’s belongings and unsanitary items to accumulate in resident’s room. On 05/22/2026 at around 9:30 AM, R1’s room was toured and the following was observed: the room floor was filled with miscellaneous items such as boxes, picture frames, bags of stuff, bags of food supplies, toys, art supplies, house hold supplies, there is a medical bed with a half bed rail, large black bags filled, wheelchair, microwave, toiletries, and other items. It was difficult to maneuver around the bedroom; there was a small narrow path that led to the bed; it was not possible to open the bedroom window because the floor was covered with miscellaneous items (as mentioned above). R1’s bathroom was toured and the following was observed: the bathroom bathtub/shower was filled with clothing items and other miscellaneous supplies. The shower curtain rod was used as a closet rod that holds about forty-seven (47) hangers with long sleeve t-shirts, sweaters, sweatpants, etc. The bathroom sink was filled with dirty dishes. Vermin droppings and dead vermin were observed in the bathroom. On 05/29/2026, R1’s room was toured and two (2) kitchen knives were observed out. (Several pictures of R1’s room were taken and video footage). Interviews conducted with W1 revealed the following: W1 agreed with the allegation. W1 explained that the facility has not addressed R1’s hoarding; furthermore, W1 states that they have witnessed one (1) to four (4) portable urinal bottles filled with urine at one time on several occasions. Interviews conducted with R2 to R9 revealed the following: Five (5) out of eight (8) residents agreed with the allegation. Residents indicated that R1 was a “pack rat,” “hoarder,” and they had observed cups filled with urine. Three (3) out of eight (8) residents could not corroborate towards the allegation (residents had not seen R1’s room). Interviews conducted with Staff 1 (S1) to Staff 6 (S6) revealed the following: Six (6) out of six (6) staff agreed that R1 has a hoarding problem which makes it difficult for R1 to remove items from their room. Staff indicated that R1 uses a wheelchair, is a large person, and were unsure how R1 maneuvered in their room. Furthermore, staff indicated that it was difficult to work inside R1’s room due to it being difficult to ambulate in the room. Moreover, staff indicated that they had observed portable urinals filled with urine. Additionally, staff indicated that R1 was unable to shower in their bathroom because it was filled with clothing items. Staff indicated since the date they began working in the facility R1’s room has been like this (filled with boxes, art supplies, etc.). Staff were unaware if Unusual Incident Reports and Adult Protective Services (APS SOC341) reports were submitted to the department. Staff were unaware if there was a specific detailed plan in place to decrease the number of items R1 had. R1’s records reviewed revealed the following: Admission Agreement was not signed nor dated by R1 nor facility staff but stated that date of Admission was 04/25/17; on page 11 under “9. Clutter No hoarding or clutter is allowed in the units. Blocking the walkways, exit areas, and air/heat unit is a safety hazard.”; R1 is “Self-Responsible.” Physicians Report dated 04/24/2023 (report not signed by R1), stated that R1 needs assistance with bathing, grooming, toileting needs, and is non-ambulatory due to both mental and physical condition. Internal Resident Incident Report dated 01/27/2025, stated that the facility contacted R1’s family about R1 being a fall risk and room being a fire hazard; family indicated they are aware of R1’s “hoarding in the past.” Appraisal/Needs And Services Plan (ANS) dated 01/30/2025 was not signed by R1 nor facility staff; document stated that R1 required assistance with Activities of Daily Living (ADLs); it stated that on 01/08/2025, “staff reported that the resident’s room had become excessively cluttered, making it difficult to move around safely. The resident also reported seeing roaches in the room.”; under “Physical/Health” it stated “Environmental/Safety Needs” “Provide a constant supervision and assistance maintaining a clean, safe, and uncluttered living space” and “all staff” will be involved daily. Internal Resident Incident Report dated 02/06/2025, indicated that R1 was hospitalized and not in the facility. Friendly Reminder letter dated 02/20/2025, stated that R1 was not complying with the facilities House Rules and/or policies, referenced House Rule 9, and stated that R1 had until 03/20/2025 to clear out the room; the letter went on to explain that “The room is extremely cluttered. This poses a fire risk and makes it difficult for our staff to assist R1 ”; furthermore, it indicated failure to resolve will lead to the beginning of eviction proceedings. Internal Resident Incident Report dated 03/11/2025, described R1’s room as a fire hazard. Internal Resident Incident Report dated 03/22/2025, indicated that R1’s room still needs to be de-cluttered. Internal Resident Incident Report dated 02/17/2026, indicated that R1 went to the hospital. Substantiated: Based on observations, interviews and record reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Executive Director, Ace Huynh.